Bronchopleural Fistula

Excerpt

A bronchopleural fistula (BPF) is a severe postoperative complication seen in thoracic surgery characterized by a sinus tract between the bronchus (main stem, lobar, or segmental) and the pleural space. This condition can result in serious complications, including respiratory insufficiency, pneumonia in the remaining lung, and empyema. BPF occurs in approximately 1.5% to 12.5% of pneumonectomy cases and about 1% of lobectomy or sublobar resection procedures and has a morbidity ranging between 25% and 71%. Causes include surgical complications, pulmonary infections resulting in necrosis, spontaneous pneumothorax, chemotherapy, radiotherapy, and tuberculosis.

BPF is a complex condition that is often challenging for clinicians to diagnose and manage. Patients with BPF present with a range of symptoms, from acute tension pneumothorax to subacute empyema, typically within the first 2 weeks following lung resection. Diagnosis involves clinical assessment, blood tests, chest computed tomography scans, and flexible bronchoscopy. Treatment strategies vary from medical management and bronchoscopic procedures to surgical interventions for those deemed with the highest risk. Management of BPF requires an interprofessional team approach involving immediate chest tube drainage, supportive care, antibiotics, and potentially surgical or bronchoscopic fistula closure.

The optimal management of BPF lacks consensus due to varying therapeutic success. Varoli et al classified fistulas by the time of their onset following surgical intervention. These classifications were divided into 3 primary time frames: early fistulas occurring within 1 to 7 days, intermediate fistulas occurring in 8 to 30 days, or late fistulas developing after more than 30 days. Although fistulas almost always occur within 3 months after surgery, BPF following pleuropulmonary infection can happen at any point. Also, managing airway pressures is crucial in those who are mechanically ventilated to promote healing and adequate ventilation. Bronchoscopic methods, such as endobronchial injections and sealants, provide temporary closure and can be a bridge to curative surgery.

To reduce BPF risk, preventative measures during initial surgeries (eg, wrapping the trachea or carina with a muscle flap or pericardium), particularly in tracheal resections, carina reconstructions, or pulmonary sleeve lobectomies, are often employed. Monitoring after closure involves clinical assessment, chest tube output, and imaging to detect recurrence or complications. Persistent or complex cases might necessitate repeat interventions or, rarely, open-window thoracostomies.